Black men who have sex with men (MSM) in the Southeastern United States are disproportionately affected by HIV. Black MSM are more likely to have unrecognized HIV infection, suggesting that testing may occur later and/or infrequently relative to current recommendations. The objective of this qualitative study was to explore the HIV testing behaviors of Black MSM in Atlanta, Georgia, who were participants in the HIV Prevention Trials Network Brothers Study (HPTN 061).
Methods and Findings
We conducted 29 in-depth interviews and four focus groups with a community-recruited sample. Modified grounded theory methodologies were used to guide our inductive analysis, which yielded a typology comprised of four distinct HIV testing patterns. Participants could be categorized as: (1) Maintenance Testers, who tested regularly as part of routine self-care; (2) Risk-Based Testers, whose testing depended on relationship status or sexual behavior; (3) Convenience Testers, who tested irregularly depending on what testing opportunities arose; or (4) Test Avoiders, who tested infrequently and/or failed to follow up on results. We further characterized these groups with respect to age, socioeconomic factors, identity, stigma and healthcare access.
Our findings highlight the heterogeneity of HIV testing patterns among Black MSM, and offer a framework for conceptualizing HIV testing in this group. Public health messaging must account for the diversity of Black MSM's experiences, and multiple testing approaches should be developed and utilized to maximize outreach to different types of testers.
Despite the availability of antiretroviral therapy (ART), HIV-infected drug users, particularly crack cocaine users, continue to have high HIV-related morbidity and mortality. We conducted a cross-sectional analysis of the baseline data for hospitalized HIV-infected crack cocaine users recruited for Project HOPE (Hospital Visit Is an Opportunity for Prevention and Engagement with HIV-Positive Crack Users) in Atlanta and Miami who were eligible for ART (reported any lifetime use of ART or CD4 <350 cells/μl). Among 350 eligible participants, whose mean age was 44.9 years (SD 7.0), 49% were male, 90% were black, and 81% were heterosexual. The median CD4 count was 144 cells/μl, and 78 of 350 (22%) were taking ART. We conducted a multivariable logistic regression to examine individual, interpersonal, and structural factors as potential correlates of ART use. Reporting ≥2 visits to outpatient HIV care in the past 6 months (AOR 7.55, 95% CI 3.80–14.99), drug or alcohol treatment in the past 6 months (AOR 2.29, 95% CI 1.06–4.94), and study site being Miami (AOR 2.99, 95% CI 1.56–5.73) were associated with ART use. Current homelessness (AOR 0.41, 95% CI 0.20–0.84) and CD4 <200 cells/μl (AOR 0.29, 95% CI 0.15–0.55) were negatively associated with ART use. Among those taking ART, 60% had an HIV-1 viral load <400 copies/ml; this represented 9% of the eligible population. For HIV-infected crack cocaine users, structural factors may be as important as individual and interpersonal factors in facilitating ART utilization. Few HIV+ crack cocaine users had viral suppression, but among those on ART, viral suppression was achievable.
Background. The Step Study tested whether an adenovirus serotype 5 (Ad5)–vectored human immunodeficiency virus (HIV) vaccine could prevent HIV acquisition and/or reduce viral load set-point after infection. At the first interim analysis, nonefficacy criteria were met. Vaccinations were halted; participants were unblinded. In post hoc analyses, more HIV infections occurred in vaccinees vs placebo recipients in men who had Ad5-neutralizing antibodies and/or were uncircumcised. Follow-up was extended to assess relative risk of HIV acquisition in vaccinees vs placebo recipients over time.
Methods. We used Cox proportional hazard models for analyses of vaccine effect on HIV acquisition and vaccine effect modifiers, and nonparametric and semiparametric methods for analysis of constancy of relative risk over time.
Results. One hundred seventy-two of 1836 men were infected. The adjusted vaccinees vs placebo recipients hazard ratio (HR) for all follow-up time was 1.40 (95% confidence interval [CI], 1.03–1.92; P = .03). Vaccine effect differed by baseline Ad5 or circumcision status during first 18 months, but neither was significant for all follow-up time. The HR among uncircumcised and/or Ad5-seropositive men waned with time since vaccination. No significant vaccine-associated risk was seen among circumcised, Ad5-negative men (HR, 0.97; P = 1.0) over all follow-up time.
Conclusions. The vaccine-associated risk seen in interim analysis was confirmed but waned with time from vaccination.
Clinical Trials Registration. NCT00095576.
The site of extrapulmonary tuberculosis infection has a known effect on mortality. Authors use a large clinical case series to identify previously unconfirmed risk factors that are associated with site of extrapulmonary tuberculosis infection.
Background. In the United States, the proportion of patients with extrapulmonary tuberculosis (EPTB) has increased relative to cases of pulmonary tuberculosis. Patients with central nervous system (CNS)/meningeal and disseminated EPTB and those with human immunodeficiency virus (HIV)/AIDS have increased mortality. The purpose of our study was to determine risk factors associated with particular types of EPTB.
Methods. We retrospectively reviewed 320 cases of EPTB from 1995–2007 at a single urban US public hospital. Medical records were reviewed to determine site of EPTB and patient demographic and clinical characteristics. Multivariable logistic regression analyses were performed to determine independent associations between patient characteristics and site of disease.
Results. Patients were predominantly male (67%), African American (82%), and US-born (76%). Mean age was 40 years (range 18–89). The most common sites of EPTB were lymphatic (28%), disseminated (23%), and CNS/meningeal (22%) disease. One hundred fifty-four (48.1%) were HIV-infected, 40% had concomitant pulmonary tuberculosis, and 14.7% died within 12 months of EPTB diagnosis. Multivariable analysis demonstrated that HIV-infected patients were less likely to have pleural (adjusted odds ratio [AOR] 0.3; 95% confidence interval [CI] .2, .6) as site of EPTB disease than HIV-uninfected patients. Among patients with EPTB and HIV-infection, patients with CD4 lymphocyte cell count <100 were more likely to have severe forms of EPTB (CNS/meningeal and/or disseminated) (AOR 1.6; 95% CI, 1.0, 2.4).
Conclusions. Among patients hospitalized with EPTB, patients coinfected with HIV and low CD4 counts were more likely to have CNS/meningeal and disseminated disease. Care for similar patients should include consideration of these forms of EPTB since they carry a high risk of death.
We examined the acceptability of the influenza A (H1N1) and seasonal vaccinations immediately following government manufacture approval to gauge potential product uptake in minority communities. We studied correlates of vaccine acceptance including attitudes, beliefs, perceptions, and influenza immunization experiences, and sought to identify communication approaches to increase influenza vaccine coverage in community settings.
Adults ≥ 18 years participated in a cross-sectional survey from September through December 2009. Venue-based sampling was used to recruit participants of racial and ethnic minorities.
The sample (N=503) included mostly lower income (81.9%, n=412) participants and African Americans (79.3%, n=399). Respondents expressed greater acceptability of the H1N1 vaccination compared to seasonal flu immunization (t=2.86, p=0.005) although H1N1 vaccine acceptability was moderately low (38%, n=191). Factors associated with acceptance of the H1N1 vaccine included positive attitudes about immunizations [OR=0.23, CI (0.16, 0.33)], community perceptions of H1N1 [OR=2.15, CI (1.57, 2.95)], and having had a flu shot in the past 5 years [OR=2.50, CI (1.52, 4.10). The factors associated with acceptance of the seasonal flu vaccine included positive attitudes about immunization [OR=0.43, CI (0.32, 0.59)], community perceptions of H1N1 [OR=1.53, CI (1.16, 2.01)], and having had the flu shot in the past 5 years [OR=3.53, CI (2.16, 5.78)]. Participants were most likely to be influenced to take a flu shot by physicians [OR=1.94, CI (1.31, 2.86)]. Persons who obtained influenza vaccinations indicated that Facebook (χ2=11.7, p=.02) and Twitter (χ2=18.1, p=.001) could be useful vaccine communication channels and that churches (χ2=21.5, p<.001) and grocery stores (χ2=21.5, p<.001) would be effective “flu shot stops” in their communities.
In this population, positive vaccine attitudes and community perceptions, along with previous flu vaccination, were associated with H1N1 and seasonal influenza vaccine acceptance. Increased immunization coverage in this community may be achieved through physician communication to dispel vaccine conspiracy beliefs and discussion about vaccine protection via social media and in other community venues.
H1N1 Vaccine; Acceptability; Vaccine Refusal; Immunization Coverage; Minorities
The Step Study, a Phase IIb HIV vaccine proof of concept study, enrolled approximately 3,000 persons in Clade B regions. The Atlanta site sought to enroll a diverse population. This prospective cohort study examined key factors associated with participant enrollment.
We obtained participant information (e.g., sociodemographic, medical) and followed outcomes from 2005 to 2007. Of the 810 potential “Step Study” participants, 340 cases were analyzed.
The recruitment strategy generated strong interest among minorities with 37% eligible following prescreening, yet 25% of the minorities enrolled. However, the percentage of whites increased from 62% eligible (prescreened sample) to 75% enrolled. The regression model was significant with educational level being an enrollment predictor (p = 0.0023). Those with at least a bachelor’s degree were more likely to enroll compared to those with a K-12 education or some college (OR = 2.424, 95% CI = 1.372–4.281, p < 0.01). White race was also a significant factor (OR=2.330; 95% CI = 1.241–4.375, p < 0.01). No difference in enrollment was observed among recruitment approaches, Pearson χ2 (2, N = 336) = 5.286, p = 0.07.
The results from this study indicate that women, minorities, and those with lower educational attainment were less likely to enroll in an HIV vaccine efficacy study at our site. The findings highlight an important consideration on the role of health literacy to sustain participation of eligible minorities in HIV vaccine trials.
HIV Vaccine; Willingness-to-Participate; Recruitment; Retention; Women; Minorities
In the United States, men who have sex with men (MSM) constitute the risk group in which the prevalence of new HIV infection is increasing. The percentage of undiagnosed HIV infection and HIV risk behaviors in MSM and non-MSM participating in an emergency department-based rapid HIV screening program were compared. Medical records of all male patients participating in the program from May 2008 to October 2010 were reviewed. MSM were identified as male or male-to-female patients reporting oral and/or anal sex with a male. Males eligible for testing were aged 18 or older, English-speaking, not known to be HIV infected, and able to decline testing. A total of 6672 males were approached for testing; 5610 (84.1%) accepted, 366 (6.5%) were MSM, and 5244 (93.5%) were non-MSM. A total of 90.7% were black. Median age was 41. Fifty-nine MSM (16.1%) were diagnosed with HIV compared to 81 (1.5%) non-MSM. MSM were 10 times more likely than non-MSM to have undiagnosed HIV infection (odds ratio [OR] 10.4, 95% confidence interval [CI] 7.3, 14.0). HIV-infected MSM (median age, 26) were younger than non-MSM (median age, 41). HIV-infected non-MSM were 2 times more likely than MSM to have CD4 counts less than 200 cells per microliter. MSM were more likely to report previous HIV testing (OR 1.9, 95% CI 1.4, 2.5) and risk behaviors, including sex without a condom (OR 2.0, 95% CI 1.5, 2.6), sex with an HIV-infected partner (OR 14.6, 95% CI 8.3, 25.6) and sex with a known injection drug user (OR 4.1, 95% CI 2.0, 8.4). Further investigation of emergency department-based HIV testing and risk reduction programs targeting MSM is warranted.
(See the editorial commentary by Tossonian and Conway, on pages 10–12.)
Background. The benefits of antiretroviral therapy during early human immunodeficiency virus type 1 (HIV-1) infection remain unproved.
Methods. A5217 study team randomized patients within 6 months of HIV-1 seroconversion to receive either 36 weeks of antiretrovirals (immediate treatment [IT]) or no treatment (deferred treatment [DT]). Patients were to start or restart antiretroviral therapy if they met predefined criteria. The primary end point was a composite of requiring treatment or retreatment and the log10 HIV-1 RNA level at week 72 (both groups) and 36 (DT group).
Results. At the June 2009 Data Safety Monitoring Board (DSMB) review, 130 of 150 targeted participants had enrolled. Efficacy analysis included 79 individuals randomized ≥72 weeks previously. For the primary end point, the IT group at week 72 had a better outcome than the DT group at week 72 (P = .005) and the DT group at week 36 (P = .002). The differences were primarily due to the higher rate of progression to needing treatment in the DT group (50%) versus the IT (10%) group. The DSMB recommended stopping the study because further follow-up was unlikely to change these findings.
Conclusions. Progression to meeting criteria for antiretroviral initiation in the DT group occurred more frequently than anticipated, limiting the ability to evaluate virologic set point. Antiretrovirals during early HIV-1 infection modestly delayed the need for subsequent treatment.
Clinical Trials Registration. NCT00090779.
Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) continue to be a significant public health concern in the United States. It disproportionately affects persons in the Deep South of the United States, specifically African Americans. This is a descriptive report of an Emergency Department (ED)-based HIV screening program in the Deep South using the 2006 Centers for Disease Control and Prevention (CDC) recommendations for rapid testing and opt-out consent. Between May 2008 and March 2010, patients presenting for medical care to the ED Monday through Friday between 10 am and 10 pm were approached for HIV screening. Patients were eligible for screening if they were 18 or older, had no previous history of positive HIV tests, were English-Speaking, and were not incarcerated, medically unstable, or otherwise able to decline testing. All patients were tested using the OraQuick® rapid HIV 1/2 antibody test. Patients with non-reactive results were referred to community anonymous testing sites for further testing. Patients with reactive results had confirmatory Western blot and CD4 counts drawn and were brought back to the ED for disclosure of the results. All patients with confirmed HIV positive via reactive Western blot were referred to the hospital-based infectious disease clinic or county health department. We tested 7,616 patients out of 8,922 approached. The overall test acceptance rate was 85.4%. 91.0% of patients tested were African American. The most common reason for refusal was recent HIV test. 1.7% of patients tested were confirmed HIV positive via Western blot. 95.2% of patients testing HIV positive were African American. The average CD4 count for patients testing positive was 276 cells/μl, with 42.0% of patients having CD4 counts ≤200 μl, consistent with an AIDS diagnosis. 88.4% of patients who had reactive oral swabs returned for Western blot results and 75.0% of patients attended their first clinic visit. We have been able to successfully carry out an ED-based HIV screening program in a resource-poor urban teaching facility in the Deep South. We define our success based on our relatively high test acceptance rate and high rate of attendance at first clinic visit. Our patient population has a relatively high undocumented HIV prevalence and are at advanced stage of disease at the time of diagnosis.
Rapid HIV screening; Emergency Department; Southeastern United States
Depression contributes to worse general and HIV-related clinical outcomes. We examined the prevalence of and factors associated with depressive symptomatology among HIV-infected crack cocaine users recruited for Project HOPE (Hospital Visit is an Opportunity for Prevention and Engagement with HIV-positive Crack Users). We used multiple logistic regression to determine socio-demographic correlates associated with screening in for depression. Among 291 participants, three-quarters (73.5%) were identified as depressed. Higher odds of screening in for depression was associated with food insufficiency and monthly income below $600. Alcohol and crack use were not associated with screening in for depression. Depressive symptomatology is extremely prevalent among HIV-infected crack cocaine users and is associated with food insufficiency and lower income. Screening for depression and food insecurity should be included in HIV prevention and treatment programs. Improved recognition and mitigation of these conditions will help alleviate their contribution to HIV-related adverse health outcomes.
Depression; HIV/AIDS; Food insecurity; Crack cocaine
Multiple intravaginal HIV prevention methods, including microbicide gels, barriers, and intravaginal rings, are in clinical development in Africa. Development of intravaginal HIV prevention products requires an understanding of sexual behavior, sexually transmitted infection (STI), and vaginitis prevalences, and sexual and vaginal practices in potential target populations. We assessed these factors in a cohort of Kenyan female sex workers (FSW). Women who reported exchanging sex for money/gifts at least three times in the past month and who were HIV uninfected were enrolled and followed for 6 months. STI prevalence and HIV incidence were analyzed by multivariate logistic regression analysis, controlling for demographic and behavioral factors. Thirty-seven percent (74/200) reported having had anal sex. Frequency of anal sex was higher with regular and casual partners than with primary partners. Women were less likely to use condoms for anal sex than for vaginal sex with regular or casual partners. Vaginal washing was universal (100%). HIV incidence was 5.6 per 100 person-years (95% CI 1.62, 11.67). HIV incidence was not associated with any demographic or risk behavior. The relatively high rate of anal sex and universal vaginal washing may complicate both safety and efficacy evaluation of intravaginal products and should be taken into account in trial design. This FSW population had significant HIV incidence and needs continued HIV prevention interventions.
This study investigated socioecological factors influencing HIV vaccine research participation among communities living in geographic areas with high HIV prevalence and high poverty rates.
We surveyed a sample of 453 adults ≥ 18 years from areas of high poverty and high HIV prevalence in metro Atlanta and differentiated the effects of individual-, social/organizational-, and community-level characteristics on participation in HIV vaccine research via multilevel modeling techniques that incorporated questionnaire, program, and census data.
Models that adjusted for both individual-level covariates (such as race, gender, attitudes, and beliefs concerning HIV research), social/organizational- and community-level factors such as local HIV prevalence rates, revealed that the extent of HIV prevention-related programs and services in census tracts contributed to individuals’ likelihood of participation in an HIV vaccine study. Additionally, neighborhood-based organizations offering HIV medical and treatment programs, support groups, and services (e.g., food, shelter, and clothing) encourage greater HIV vaccine research participation.
The findings support the hypothesis that community-level factors facilitate participation in HIV vaccine research independent of both individual- and social/organizational-level factors.
HIV/AIDS; HIV Vaccine; Socioecological Model; Community Engagement; Willingness to Participate; Recruitment
Gonococcal isolates (n = 4336) were collected from men with urethritis at the Fulton County STD Clinic from 1988 – 2006. Antimicrobial susceptibility was performed by agar dilution. Increasing numbers of isolates from MSM and with fluoroquinolone resistance were noted. New antimicrobials effective against gonorrhea are urgently needed.
gonorrhea; fluoroquinolone resistance (QRNG); GISP; Atlanta
What would you do if you had a sexually transmitted disease that was untreatable with antibiotics? That is the situation we may be heading toward. In the United States, gonorrhea is the second most common reportable infection. Over the years, the organism that causes it, N. gonorrhoeae, has acquired resistance to several classes of antibiotics including, most recently, the fluoroquinolones. In fact, widespread resistance led CDC to stop recommending fluoroquinolones for gonorrhea treatment in 2007. Today, cephalosporin-based combination therapy is the last remaining option currently recommended for gonorrhea treatment. Understanding of the causes of drug resistance is needed so that control measures can be improved and the effectiveness of the few remaining drugs can be maintained. This article investigates possible causes for the emergence of fluoroquinolone-resistant N. gonorrhoeae that occurred several years ago. Fluoroquinolone-resistant strains spread in the United States in the late 1990s and spread more rapidly among men who have sex with men (MSM) than among heterosexual men. One possible explanation for the rise in drug resistance, especially among heterosexuals, is acquisition of resistant gonorrhea through travel. Certain drug-resistant strains of N. gonorrhoeae, particularly the multidrug resistant strains (also resistant to penicillin and tetracycline) circulating among MSM, seemed to be able to reach high prevalence levels through domestic transmission, rather than through frequent importation. After resistance emerged in a geographic area, resistant strains appeared among MSM and heterosexuals within several months. When resistance is detected in either MSM or heterosexuals, prevention efforts should be directed toward both populations.
Using data from the Gonococcal Isolate Surveillance Project, we studied changes in ciprofloxacin resistance in Neisseria gonorrhoeae isolates in the United States during 2002–2007. Compared with prevalence in heterosexual men, prevalence of ciprofloxacin-resistant N. gonorrhoeae infections showed a more pronounced increase in men who have sex with men (MSM), particularly through an increase in prevalence of strains also resistant to tetracycline and penicillin. Moreover, that multidrug resistance profile among MSM was negatively associated with recent travel. Across the surveillance project sites, first appearance of ciprofloxacin resistance in heterosexual men was positively correlated with such resistance for MSM. The increase in prevalence of ciprofloxacin resistance may have been facilitated by use of fluoroquinolones for treating gonorrhea and other conditions. The prominence of multidrug resistance suggests that using other classes of antimicrobial drugs for purposes other than treating gonorrhea helped increase the prevalence of ciprofloxacin-resistant strains that are also resistant to those drugs.
Neisseria gonorrhoeae; antimicrobial resistance; men who have sex with men; multidrug resistance; MSM; bacteria; gonorrhea; United States; ciproflaxin; luoroquinolones
Diabetic heart disease is a distinct clinical entity that can progress to heart failure and sudden death. However, the mechanisms responsible for the alterations in excitation-contraction coupling leading to cardiac dysfunction during diabetes are not well known. Hyperglycemia, the landmark of diabetes, leads to the formation of advanced glycation end products (AGEs) on long-lived proteins, including sarcoplasmic reticulum (SR) Ca2+ regulatory proteins. However, their pathogenic role on SR Ca2+ handling in cardiac myocytes is unknown. Therefore, we investigated whether an AGE cross-link breaker could prevent the alterations in SR Ca2+ cycling that lead to in vivo cardiac dysfunction during diabetes. Streptozotocin-induced diabetic rats were treated with alagebrium chloride (ALT-711) for 8 weeks and compared to age-matched placebo-treated diabetic rats and healthy rats. Cardiac function was assessed by echocardiographic examination. Ventricular myocytes were isolated to assess SR Ca2+ cycling by confocal imaging and quantitative Western blots. Diabetes resulted in in vivo cardiac dysfunction and ALT-711 therapy partially alleviated diastolic dysfunction by decreasing isovolumetric relaxation time and myocardial performance index (MPI) (by 27 and 41% vs. untreated diabetic rats, respectively, P < 0.05). In cardiac myocytes, diabetes-induced prolongation of cytosolic Ca2+ transient clearance by 43% and decreased SR Ca2+ load by 25% (P < 0.05); these parameters were partially improved after ALT-711 therapy. SERCA2a and RyR2 protein expression was significantly decreased in the myocardium of untreated diabetic rats (by 64 and 36% vs. controls, respectively, P < 0.05), but preserved in the treated diabetic group compared to controls. Collectively, our results suggest that, in a model of type 1 diabetes, AGE accumulation primarily impairs SR Ca2+ reuptake in cardiac myocytes and that long-term treatment with an AGE cross-link breaker partially normalized SR Ca2+ handling and improved diabetic cardiomyopathy.
cardiomyopathy; sarcoplasmic reticulum Ca2+-ATPase pump; diastolic function; type 1 diabetes; alagebrium chloride (ALT-711)
The live yellow fever vaccine (YF-17D) offers a unique opportunity to study memory CD8+ T cell differentiation in humans following an acute viral infection. We have performed a comprehensive analysis of the virus-specific CD8+ T cell response using overlapping peptides spanning the entire viral genome. Our results showed that the YF-17D vaccine induces a broad CD8+ T cell response targeting several epitopes within each viral protein. We identified a dominant HLA-A2-restricted epitope in the NS4B protein and used tetramers specific for this epitope to track the CD8+ T cell response over a 2 year period. This longitudinal analysis showed the following. 1) Memory CD8+ T cells appear to pass through an effector phase and then gradually down-regulate expression of activation markers and effector molecules. 2) This effector phase was characterized by down-regulation of CD127, Bcl-2, CCR7, and CD45RA and was followed by a substantial contraction resulting in a pool of memory T cells that re-expressed CD127, Bcl-2, and CD45RA. 3) These memory cells were polyfunctional in terms of degranulation and production of the cytokines IFN-γ, TNF-α, IL-2, and MIP-1β. 4) The YF-17D-specific memory CD8+ T cells had a phenotype (CCR7−CD45RA+) that is typically associated with terminally differentiated cells with limited proliferative capacity (TEMRA). However, these cells exhibited robust proliferative potential showing that expression of CD45RA may not always associate with terminal differentiation and, in fact, may be an indicator of highly functional memory CD8+ T cells generated after acute viral infections.
The use of stable isotopes in ecological studies requires that we know the magnitude of discrimination factors between consumer and element sources. The causes of variation in discrimination factors for carbon and nitrogen have been relatively well studied. In contrast, the discrimination factors for hydrogen have rarely been measured. We grew cabbage looper caterpillars (Trichoplusia ni) on cabbage (Brassica oleracea) plants irrigated with four treatments of deuterium-enriched water (δD = −131, −88, −48, and −2‰, respectively), allowing some of them to reach adulthood as moths. Tissue δD values of plants, caterpillars, and moths were linearly correlated with the isotopic composition of irrigation water. However, the slope of these relationships was less than 1, and hence, discrimination factors depended on the δD value of irrigation water. We hypothesize that this dependence is an artifact of growing plants in an environment with a common atmospheric δD value. Both caterpillars and moths were significantly enriched in deuterium relative to plants by ∼45‰ and 23‰ respectively, but the moths had lower tissue to plant discrimination factors than did the caterpillars. If the trophic enrichment documented here is universal, δD values must be accounted for in geographic assignment studies. The isotopic value of carbon was transferred more or less faithfully across trophic levels, but δ15N values increased from plants to insects and we observed significant non-trophic 15N enrichment in the metamorphosis from larvae to adult.
Poor engagement in HIV care is common in the United States and worsens HIV treatment outcomes. In addition, poor engagement in care is likely to drastically reduce the effectiveness of “test and treat” HIV prevention strategies.
(See the editorial commentary by Lange, on pages 801–802.)
For individuals with human immunodeficiency virus (HIV) infection to fully benefit from potent combination antiretroviral therapy, they need to know that they are HIV infected, be engaged in regular HIV care, and receive and adhere to effective antiretroviral therapy. Test-and-treat strategies for HIV prevention posit that expanded testing and earlier treatment of HIV infection could markedly decrease ongoing HIV transmission, stemming the HIV epidemic. However, poor engagement in care for HIV-infected individuals will substantially limit the effectiveness of test-and-treat strategies. We review the spectrum of engagement in care for HIV-infected individuals in the United States and apply this information to help understand the magnitude of the challenges that poor engagement in care will pose to test-and-treat strategies for HIV prevention.
We assessed prevalent HIV cases in Atlanta to examine case distribution trends and population characteristics at the census tract level that may be associated with clustering effects. We calculated cluster characteristics (area and internal HIV prevalence) via Kuldorff's spatial scan method. Subsequent logistic regression analyses were performed to analyze sociodemographics associated with inclusion in a cluster. Organizations offering voluntary HIV testing and counseling services were identified and we assessed average travel time to access these services. One large cluster centralized in downtown Atlanta was identified that contains 60% of prevalent HIV cases. The prevalence rate within the cluster was 1.34% compared to 0.32% outside the cluster. Clustered tracts were associated with higher levels of poverty (OR = 1.19), lower density of multi-racial residents (OR = 1.85), injection drug use (OR = 1.99), men having sex with men (OR = 3.01), and men having sex with men and IV drug use (OR = 1.6). Forty-two percent (N = 11) of identified HIV service providers in Atlanta are located in the cluster with an average travel time of 13 minutes via car to access these services (SD = 9.24). The HIV epidemic in Atlanta is concentrated in one large cluster characterized by poverty, men who have sex with men (MSM), and IV drug usage. Prevention efforts targeted to the population living in this area as well as efforts to address the specific needs of these populations may be most beneficial in curtailing the epidemic within the identified cluster.
HIV/AIDS; HIV prevalence; Spatial cluster detection; Geographic mapping
We developed the Clinical Research Involvement Scales (CRIS) to assess clinical trial willingness-to-participate.
Study Design and Setting
Diverse populations (N=919) aged ≥ 18 years from Atlanta, Georgia were included in comprehensive testing of the 41-item CRIS instrument. The formative phase focused on item content for the new measures (n=54). Questionnaires from potential vaccine trial participants (n=865) collected at multiple timepoints resulted in evaluation of scale reliability and validity (i.e., attitudes, behavioral and normative beliefs, perceived social support for clinical research participation, social norm compliance, perceptions of the clinical research organization, and perceived relevance of the research endeavor).
Qualitative testing revealed adequate comprehension and content validity of the initial item set. The subjective norms domain (n=3) initially exhibited poor internal consistency in pilot testing (Cronbach's α = 0.525), yet rewording of the items resulted in consistently stable measurement improvement (Cronbach's α = 0.850). Each of the CRIS subscales demonstrated extremely high reliability, ranging from 0.734 – 0.918. Confirmatory factor analysis verified item-factor relationships and determined construct and convergent validity (RMSEA=.068; CFI=0.835).
CRIS is a reliable instrument for measuring community attitudes toward participation in biomedical research studies. Results of this study support the use of these scales to recruit diverse populations to clinical trials.
HIV Psychometrics; HIV Vaccines; Patient Selection; African Americans; Women
The study is aimed at identifying clinical, demographic and behavioral factors, including participation in HIV care, associated with the utilization of antiretroviral therapy (ART), among hard-to-reach HIV-positive individuals in Atlanta, GA. The study included 184 HIV-positive participants of the Infectious Disease Program (IDP) of the Grady Health System between February 1999 to March 2001. Individuals were categorized as regular attendees (those who consistently kept their outpatient appointments, n = 65), irregular (those who inconsistently kept their appointments, n = 60) or non-attendees (those who failed routinely to keep their appointments, n = 59). Univariate and multivariate analyses using log-binomial regression modeling were done. HIV-infected individuals who consistently kept their appointments at the IDP received ART at a frequency (86%) that is twice that of those who missed some appointments (42%) and four times that of those who routinely failed to keep appointments (20%). In multivariate analysis, category of clinic attendance (regular, irregular or non-attendee) was the only risk factor independently associated with utilization of ART: Regular attendees (RR = 3.59, 95% CI 2.12 to 6.08) and irregular attendees (RR = 2.26, 95% CI 1.28 to 4.01) compared to non-attendees. The positive association between routine clinic attendance and use of antiretroviral therapy observed in this study should encourage the development of strategies to retain patients in outpatient HIV care.
Antiretroviral therapy (ART); HIV-infected individuals; Georgia